Provider Demographics
NPI:1467511204
Name:SQUIRES, JOHN A
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1573
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44901-1573
Mailing Address - Country:US
Mailing Address - Phone:419-526-4603
Mailing Address - Fax:419-526-4603
Practice Address - Street 1:87 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-1672
Practice Address - Country:US
Practice Address - Phone:419-526-4603
Practice Address - Fax:419-526-4603
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0001662-SUPV101Y00000X, 101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral